Linking local clinical and social service organizations to better meet patients' needs
Patients with unmet social needs, such as food insecurity, housing instability, and lack of transportation, tend to have worse health outcomes. As new payment models shift more responsibility for those outcomes onto payers and providers, they have become more invested in addressing patients’ social needs. However, it can be challenging for time-strapped providers to identify the right local resources and then follow through on referrals.
Unite Us is a technology company that links social service organizations and the providers whose patients need their services, which include stable and affordable housing; maternal, infant, and child health services; healthy food; mental health counseling; and chronic disease management programs. Using Unite Us’s digital platform, clinical and social service providers can communicate in real-time and track referrals and their outcomes in detail. Unite Us also assists with the identification, credentialing, and onboarding of community-based organizations to ensure the resources listed within the network remain reliable and robust.
Unite Us has recently begun to expand its presence in California, announcing significant partnerships with both Kaiser and Dignity. By coalescing around Unite Us as their platform of choice for coordinating community referrals, the two health systems hope to encourage others to join and achieve the kind of critical mass Unite Us needs to deliver the greatest possible value and impact.
For its part, CHCF will help mobilize the support of local partners at the county level, beginning in Kern, Merced, and Stockton, and will fund an evaluation of the platform’s impact on the integration of social and clinical care. In order to support those local convening and evaluation efforts, CHCF has committed $500,000 in grant support on top of the $1 million program-related investment in Unite Us.